Company Name                         Contact Name                      MC#
                  
Address                            City                                St      Zip
   
Email Address               Website Address
  
Phone                              Fax
  
Liability Ex-Date              Company                        Premium
     
Cargo   Ex-Date              Company                        Premium
     

Trucks

Year              Make                  Type                     GVW             Value
              Conventional Cabover Straight Other      
Year              Make                  Type                     GVW             Value
              Conventional Cabover Straight Other      
Year              Make                  Type                     GVW             Value
              Conventional Cabover Straight Other      

Trailers

Year              Make                  Type                        Value
              Van ReferVan End Dump Grain Lowboy Tanker 28 Ft for Double Heavyhaul Autohauler Other  
Year              Make                  Type                        Value
              Van ReferVan End Dump Grain Lowboy Tanker 28 Ft for Double Heavyhaul Autohauler Other  
Year              Make                  Type                        Value
              Van ReferVan End Dump Grain Lowboy Tanker 28 Ft for Double Heavyhaul Autohauler Other  
Year              Make                  Type                        Value
              Van ReferVan End Dump Grain Lowboy Tanker 28 Ft for Double Heavyhaul Autohauler Other  

Commodities Hauled  Do not  say general!

Commodity                       Percentage
    
Commodity                       Percentage
    
Commodity                       Percentage
    
Commodity                       Percentage
    

Radius of operation: 0-50 0-100 0-300 300-600 600+    Intra or interstate travel: Intrastate Interstate
Do you have a Single State Registration Yes No

Drivers

Name                              Age           No of Tickets   No of Acc    Years Driving Trucks
                                                    
Name                              Age           No of Tickets   No of Acc    Years Driving Trucks
                                                    
Name                              Age           No of Tickets   No of Acc    Years Driving Trucks
                                                    
Name                              Age           No of Tickets   No of Acc    Years Driving Trucks
                                                    

Please list some of the major cities you travel through

Please list all claims in last 3 years.   If we write your account loss runs will be required.

1. 
2. 
3. 

Limits

Liability:  $750,000 $1,000,000 $5,000,000 Other    Cargo:  $25,000 $50,000 $75,000 $100,000 $150,000 Other Reefer Coverage:

Physical Damage Deductible:  $1000 $2500 Other

Cargo Deductible:  $1000 $2500 Other

Please provide any other information that may be helpful in writing your account.  If you checked Other on this application please explain in the space provided.

This form will provide Insurance Strategies,LTD with the basic information needed to review your account.  After receiving the above information, we will be better able to determine which programs you will qualify for and what additional information may be required.  We offer quick turnaround and you should be contacted within 48 hours of submitting your information.